Acute stroke is a common and devastating disorder, the 3rd leading cause of death and leading cause of adult disability in the US. This application for a Supplement to the UCLA Specialized Program of Translational Research in Acute Stroke Center proposes two research projects to complete an integrated research/training program to develop innovative therapies for acute ischemic and hemorrhagic stroke. Supplement Project 1, the "Intraoperative CT and Endovascular-Guided Surgery for Intracerebral Hemorrhage (ICES) Trial" is a critical phase 2 trial of a new, minimally invasive surgical technique for the evacuation of primary intracerebral hemorrhage, using neuroendoscopy. Through a collaboration between the UCLA SPOTRIAS ICES Surgical Center and the MISTIE (Minimally Invasive Surgery plus rt-PA for ICH Evacuation) Trialists, we will compare in a three arm randomized trial the safety profile of 1) endoscopic surgery (immediate clot removal via a minimally invasive surgical endoscope), 2) stereotactic thrombolysis (slower removal via an aspiration catheter), and 3) supportive medical care. Supplement Project 2, the "Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial" will assess the tolerabiliry, feasibility, and safety of increasing blood flow to ischemic cerebral fields through external counterpulsation in 30 patients with persisting arterial occlusion. These two Projects will be supported by the existing five UCLA Center Cores: Administrative, Patient Access, Blood/Tissue Specimen, Biostatistics/Data Management, and Neuroimaging. The Projects will also provide training opportunities for the Center Career Development Program that educates the next generation of translational scientists in neurovascular disease at the premedical, medical student, and fellowship level. PUBLIC HEALTH RELEVANCE: Acute stroke is the 3rd leading cause of death and leading cause of disability in the US. The ICES Trial will study the feasibility and safety of a new surgical treatment for hemorrhagic strokes-rapid blood removal through a small tube with fiberoptic tip guidance. The CUFFS Trial will evaluate the feasibility of a new treatment for ischemic strokes-compressing the limbs with each heartbeat to redirect blood flow to the brain.